Peri-operative care Flashcards
1
Q
What does the pre-op assessment allow for?
A
Identify co-morbidities that may cause complications during anaesthetic, surgical or post-op period (generally 2-4 weeks before surgery)
2
Q
What is asked specifically in the pre-op history?
A
PMH: CVD (risk of acute cardiac event during anaesthesia), respiratory disease, renal disease, endocrine disease (specifically DM and thyroid disease)
Risk of pregnancy? or risk of undiagnosed sickle cell disease (if african / afro-caribbean)
Previous operations
Past anaesthetic history (specifically post op N&V)
Drug history (may need changing before surgery)
Family history (malignant hyperpyrexia)
Social history (smoking, alcohol, exercise tolerance)
3
Q
What is malignant hyperpyrexia?
A
Autosomal dominant condition which result in muscle rigidity (despite neuromusclar blockade) followed by a rise in temperature caused by certain anaesthetics
4
Q
What forms the pre-operative examination?
A
General examination (for undiagnosed pathology)
Airway examination (predict difficulty of intubation)
5
Q
What is an ASA grade (given after a pre-operative assessment)?
A
Correlates with risk of post-op complications and absolute mortality (grade V - not expected to survive without operation)
6
Q
Which pre-op blood tests might be needed? Why?
A
FBC (for anaemia / thrombocytopaenia)
U&E (baseline renal function - inform IV fluid management)
LFTs (for metabolism and synthesising function)
Clotting screen (for indications of deranged coagulation e.g. iatrogenic cause - warfarin OR inherited coagulopathies - haemophilia A)
Group and save (G&S) + / - cross matching
7
Q
What is the difference between group and save and cross match?
A
Group and save = patients blood group (ABO and RhD) and screens blood for atypical antibodies (takes 40 mins)
Cross match = physically mixing the patients blood with donors bloos and seeing if immune reaction (done if blood loss anticipated)
8
Q
What imaging may be done pre-operatively?
A
CXR (if resp illness and no CXR in 12 months, new cardiorespiratory symptoms, recent travel from area endemic with TB, significant smoking history)
Spirometry (if chronic lung condition for baseline)
9
Q
Which ‘other tests’ may be required pre-operatively?
A
Pregnancy testing = ensure consent
Sickle cell test = if FH of SCC or african / afro-caribbean descent
Urinalysis = evidence / suspicion of ongoing glycosuria or UTI
MRSA swab = from nostil and perineum and or other site
10
Q
What should be look at on the pre-op air way assessment?
A
Receding mandible (retrognathia)
Degree of mouth opening (favourable if inter-incisor distance > 3cm)
Teeth (and dentition - any loose)
11
Q
What is the advice on food pre-operatively?
A
Stop eating - 6 hours before
Stop dairy products (including tea and coffee) - 6 hous before
Stop clear fluids - 2 hours before
12
Q
Why do patients need to fast before surgery?
A
To prevent pulmonary aspiration causing aspiration pneumonitis (inflammation due to acidic gastric contents) and aspiration pneumonia (due to secondary infection following pneumonitis)
13
Q
Which drugs should be stopped before surgery and when?
A
CHOW
Clopidogrel - 7 days (due to bleeding risk, aspirin and other anti-platelets can be continued)
Hypoglycaemics
Oral contraceptive pill or HRT - 4 weeks before surgery due to DVT risk
Warfarin - 5 days prior (due to bleeding risk - swapped to LMWH)
14
Q
In reference to warfarin what INR is required for surgery to go ahead?
A
INR <1.5 - may have to reverse warfarinisation with PO vitamin K
15
Q
Which drugs to alter prior to surgery?
A
Subcutaneous insulin - switched to IV variable rate insulin
Long term steroids - Orally to IV (conversion 5mg PO prednisolone = 20mg IV hydrocortisone)
16
Q
Why is steroid prescribing important in surgery?
A
The stress response will normally activate HPA axis however this has been suppressed in patients on steroid therapy (confirmed through short synacthen testing)
Thus stress dose corticosteroid therapy must be given
17
Q
Which drugs should be started prior to operations?
A
LMWH - after VTE risk assessment and appropriate prescription (exception in neck / endocrine surgery)
TED stockings - exception of vascular surgery patients (contraindicated in peripheral vascular disease, peripheral neuropathy, recent skin graft, severe eczema
Antibiotic prophylaxis - in orthopaedic, vascular, GI surgery
18
Q
What is the pre-op management of patients with T1DM?
A
First on the morning list
Night before = reduce subcut basal insulin dose by 1/3
Morning of = omit insulin, start IV variable rate insulin infusion pump (usually actrapid)
Whilst nil-by mouth = infusion 5% dextrose (usually at 125mL/hr - check capillary glucose every 2 hours and alter insulin accordingly)
After operation = continue until patient eating and drinking - then overlap IV variable rate insulin infucion and normal SC insulin
19
Q
What is the peri-op care of patients with T2DM?
A
If diet controlled = no action
Oral hypoglycaemics = metformin stopped on morning of surgery (all others stopped 24 hours before operation)
Started on IV variable rate insulin infusion along with 5% dextrose as in T1DM - post-op management same as T1DM
20
Q
When is bowel prep needed in surgery?
A
Upper GI, HPB, small bowel = none needed
Right hemi-colectomy or extended right hemi-colectomy = none
Left hemi-colectomy, sigmoid colectomy or abdominal-perineal resection = phosphate enema on morning of surgery
Anterior resection = 2 sachets of picolax the say before / phosphate enema on the morning of
21
Q
What amount of total body weight is water?
A
2/3rd (2/3rd is intracellular and 1/3rd is extracellular)
22
Q
If the aim of fluids is resuscitation where is it important that the fluids stay?
A
Intravascular space
23
Q
What are losses of fluid from non-urine sources?
A
Insensible loss
24
Q
What to look for on assessment for dehydration?
A
- Dry mucous membranes and reduced skin turgor
- Decreasing urine output (target > 0.5ml/kg/hr)
- Orthostatic hypotension
- Increased cap refill
- Tachycardia
- Low blood pressure
25
What to look for on **assessment of fluid overload**?
**Raised JVP**
**Peripheral / sacral oedema**
**Pulmonary oedema**
26
How to monitor fluid status?
**Fluid input-output chart**
**Daily weight chart**
**U&Es** (for evidence of dehydration, renak hypoperfusion or electrolyte abnormalities)
27
What are the **daily requirements** of **water, sodium, potassium and glucose**?
**Water:** 25 mL/kg/day
**Na+:** 1.0 mmol/kg/day
**K+:** 1.0 mmol/kg/day
**Glucose:** 50g/day
28
What are the **two types** of **IV fluids**?
**Crystalloids** e.g. 0.9% saline, 5% dextrose, Hartmann's solution (cheaper than colloids)
**Colloids** e.g. gelatin
29
How to correct a **fluid deficit**?
If reduced urine output (\<0.5ml/kg/hr) managed with a **fluid challenge** (either 250ml or 500ml over 15-30mins)
30
What are the **two important blood groups**?
**ABO** blood system
**Group D** of rhesus system
31
What percent of the population has **rhesus D surface antigens**?
85%
32
What is the **ABO group**?
Presence of **A and / or B antigens** on the surface of RBCs
33
Which blood is the **universal donor**?
**O-ve** (no AB or rhesus antigens on donor RBC surface(
34
Which blood is the **unversal acceptor**?
**AB +ve** (no A, B or Rhesus antibodies in circulation)
35
When should **CMV-negative blood products** be given?
Can cause **congenital infection** so should be given:
* During pregnancy
* Intra-uterine transfusions
* Neonates (up to 28 days)
36
Why are **irradiated blood products given**?
Reduce risk of **graft-versus-host-disease**
37
Who should receive irradiated blood?
* If blood from **first or second degree family members**
* Patients with **Hodgkin's Lymphoma**
* Recent **haematopoietic stem cell** transplants
* After **anti-thymocyte globulin** (ATG) or **Alemtuzumab** therapy
* Those receiving purine analogues (e.g. fludarabine) as chemo
* **Inter-uterine** transfusions
38
What are the **obsevation timings** of blood transfusions?
Before
12-20 mins after started
1 hour
At completion
39
Why should **blood products** be given through a **green** (18g) or grey (16g) cannula?
Cells **haemolyse** due to **sheering forces** in narrow tube
40
How is a blood giving set different from a normal fluid giving set?
Contains a **filter** in the chamber
41
What are the different **types** of **blood products**?
**Packed red cells** (RBCs)
**Platelets**
**Fresh frozen plasma** (clotting factors)
**Cryoprecipitate** (fibrinogen, vWF, Factor VIII, fibronectin)
42
When are **packed red cells given**? Over **how long**?
**Acute blood loss**, **chronic anaemia** (Hb \<70g/L or \<100 in CVD), **symptomatic anaemia**
Must be completed within 4 hours
43
How much should **1 unit of blood** increase a **patient's Hb by**?
**10g/L**
44
Why do you need a **new G&S** for **future transfusions**?
May **produce autoantibodies** to donor surface antigens (new if longer than 3 days of most recent transfusion)
45
When are **platelets** given and **over how long**?
**Haemorrhagic shock** in a **trauma patient**
Profound **thrombocytopaenia** (normal range 150-400)
**30 minutes**
46
When is **fresh frozen plasma** (FFP) given?
**Disseminated intravascular coagulation** (DIC)
Haemorrhage secondary to **liver disease**
Over **30 minutes**
47
When is **cryoprecipitate** given? Over **how long**?
DIC with fibrinogen
von Willebrands disease
Massive haemorrhage
**Stat**
48
What are **malnourished patients** at **increased risk of**?
**Reduced wound healing**
**Increased infection** rates
**Skin breakdown**
49
What **screening tool** can be used for **malnutrition**?
**Malnutrition universal screening tool**
50
Which **features suggest disease-related cachexia**?
**Muscle wasting**
**Loose skin**
Patient's **clothes no longer fitting**
**Aphthous ulcers**
**Angular cheilitis**
**Pressure sores**
51
What is the **hierarchy of feeding**?
Oral nutritional supplements (ONS)
Nasogastric tube feeding (NGT)
Gastrostomy feeding (PEG/RIG)
Jejunal feeding (jejunostomy)
Parenteral nutrition
52
What does a **low serum albumin** indicate?
**Chronic inflammation**, **proteinuria**, **hepatic dysfunction** (not malnutrition)
53
What are the **aspects** of **enhanced recovery after surgery**?
**Reduction in 'Nil By Mouth**' times (clear fluids up to 2 hours pre-surgery)
Pre-op **carb loading**
**Minimally invasive surgery**
**Minimising the use** of drains and NG tubes
**Reintroduction of feeding** post-operatively
Early **mobilisation**
54
When can GI surgery patients have an **enteral diet**?
Within **24 hours** of uncomplicated GI surgery
55
How should **feeding be managed** where there is an **entero-cutaneous fistula?**
**High fistula** (jejunal) = support with enteral or parenteral nutrition
**Low fistulae** (ileum / colon) = low fibre diet
Proportion of ECF that will heal spontaneously with PN is relatively small (presence of faeculaent material emanating from ECF = not an indication for parenteral nutrition)
56
How can a **reduction in stoma output** be achieved?
* Reduction in **hypotonic fluids** to 500ml / day
* Reduction in **gut motility** with lopermide / codeine phosphate
* **Reduction in secretions** with high dose **PPI** (twice a day dose)
* Low fibre diet to reduce intraluminal retention of water
57
What are the **three aspects** of the ERAS protocol?
Pre-op
Intra-op
Post-op
58
What is in the **pre-op** ERAS protocol?
Patient **education** on surgery and post-op course
**Exercise and weightloss** before the surgery
**Optimise medical management** - smoking and alcohol cessation
**Pre op fasting** (along with 12.5% carb beverage within 2 hours of surgery)
59
What forms part of the **intra-operative** ERAS protocol?
**Multimodal** and **opioid sparing alagesia** (including regional anaesthesia - avoid benzos in enderly)
**Multimodal** post-op N&V prophylaxis
**Minimally invasive surgery**
60
What forms the post-op care in ERAS?
**Adequate pain control** to allow for early ambulation
Early **oral intake**
61
What are the **advantages** of **day case surgery**?
**Shorter inpatient stays**
**Lower infection rates**
**Reduced waiting lists**
**Cheaper** than overnight stay
62
How to **prepare** for a **day case**?
Not to **eat / drink for 6 hours prior to surgery**
Most medications can continue until day of operation with **care over anti-coagulants / anti-platelets** in operations where bleeding is a risk
63
What is the **criteria** for **day case surgery**?
**Minimal blood loss** expected
**Short operating time** (\<1 hour)
No expected complications
**No specialist aftercare** needed
64
Give some examples of **day case surgeries**?
Inguinal hernias
Varicose veins
Cataract
Extraction of wisdom tooth
65
What are the **different classifications** of **haemorrhage** in the **surgical patient**?
**Primary bleeding** - during intra-operative period, resolved during operation, recorded in op notes
**Reactive bleeding** - within 24 hours of operation, usually from ligature that slips / missed vessel (due to hypotension)
**Secondary bleeding** - 7-10 days post-op (erosion of a vessel from a spreading infection)
66
What are the **clinical features** of **haemorrhagic shock**?
**Raised RR**
**Tachycardia**
**Dizziness**
**Agitation**
**Visible bleeding**
**Decreased urine output**
**Hypotension** (often late sign)
67
What is the **management** of **post-operative bleeding**?
**A to E** approach
**Adequate IV access** (18G cannula) and rapid resuscitation
**Read op notes** (location of wounds, drains)
**Direct pressure** to bleeding site
**Urgent senior surgical review**
**Urgent blood transfusion** (moderate to severe post-op haemorrhage)
68
Why is **bleeding** post **thyroidectomy** or **parathyroidectomy** so dangerous?
Causes **airway obstruction** as the pretracheal fascia of neck will only distend so far
**Compression on venous return** = venous congestion = laryngeal oedema = asphyxiation
69
Which **vessel** is **vulnerable** from **laparoscopic ports**?
**Inferior epigastric artery** (arising from external iliac artery) runs up abdominal wall, vertically in mid clavicular line
70
Which vessel is vulnerable in angio-graphy?
**External iliac artery** (goes into **retroperitoneum**)
Apply pressure to site (resus patient)
71
Which **criteria** are needed for a **diagnosis** of **sepsis**?
Presence of a known / suspected **infection**
Features of **organ dysfunction**
72
What is the qSOFA score?
Shortened version of SOFA critera - allowing for **rapid assessment** of potential sepsis based purely on **clinical signs**
73
What forms part of the **qSOFA criteria**?
**Resp rate** \> 22 / min
**Altered mental state**
**Systolic blood pressure \<100**
(if \>= 2 then treat as sepsis)
74
What is the **sepsis 6**?
**Oxygen** (15L O2 via non-rebreath mask, target sats of 94-98% or 88-92% in chronic retainers) titrate once appropriately saturated
**IV fluid therapy** (500-1000ml inital fluid bolus)
**Blood cultures** (prior to administering abx)
**IV** **abx** (empirical - based on local guidelines)
**Routine bloods inc lactate** (FBC, U&Es, LFTs, clitting, CRP, glucose, lactate from blood gas)
**Monitor urine output** (aim for \>0.5mL/kg/hour)
75
What **further management** is there for **septic patients**?
Hourly observations from nursing staff
Assessment by **intensive care teams**
**Vasopressor agents** (e.g. noradrenaline)
**Renal replacement therapy**
Ventilator support
76
What **investigations** for **source identification** in **sepsis**?
**Urine dip +/- culture**
**CXR**
**Swabs** (e.g. surgical wounds)
Operative site assessment (via CT or US)
CSF sample (via LP)
Stool culture
77
When should **clinical outreach teams** be involved in the care of a **septic patient**?
Evidence of **septic shock**
**Lactate** \> 4.0mmol
**Failure to improve** from initial management
78
What are the **7 sources** of **pyrexia** in a **surgical patient**?
**Chest** (infection)
**Cut** (infection)
**Catheter** (UTI)
**Collections** (abdo, pelvic etc)
**Calves** (DVT)
**Cannula** (infection)
**Central line** (infection)
79
What is **septic shock**?
**Sepsis with hypotension** despite **adequate fluid resuscitation**
80
What is the **management** of septic shock?
**Aggressive fluid resus** and **abx therapy**
**Inotropes** used to **maintain organ perfusion**
81
How to **objectively assess pain**?
**Tachycardia**
**Tachypnoea**
**Hypertension**
**Sweating**
**Flushing**
82
What are the **consequences** of **poor pain control**?
Slower recovery dur to:
- **Reluctance to mobilise**
- **Not breathing as deeply** (causing atelectasis)
83
What are the **steps** of the **WHO pain ladder**?
**Simple analgesics** (paracetamol or NSAIDs)
**Weak opiates** (codeine or tramadol)
**Stronger opiates** (morphine, oxycodone, fentanyl)
84
How do **NSAIDs work**?
**Inhibit** synthesis of **prostaglandins** (inhibit inflammatory response causing the pain)
85
What re the **side effects** of **NSAIDs**?
I-GRAB
**Interactions** with other medications e.g. warfarin
**Gastric** ulceration (consider adding PPI when prescribing NSAIDs long term)
**Renal** impairment (use NSAIDs sparingly here)
**Asthma** sensitivity (triggers 10% of thos with asthma)
**Bleeding** risk (due to effect on platelets)
86
How do **opioids** work?
What are their side effects?
Activate **opioid receptors** (in CNS)
**Constipation**
**Nausea**
Laxitives and anti-emetics often prescribed concurrently
87
What are the **other side effects** of **opioids**?
**Sedation**
**Confusion**
**Respiratory depression**
**Pruritus**
**Tolerance**
**Dependence**
88
What are some **prescribing tips** for **opioids**?
**Concurrent regular paracetamol**
Avoid **weak and stron opiates in combination** (competitively inhibit same receptor to varying degrees)
If renally impaired then consider oxycodone / fentanyl rather than morphine
89
What are the **advantages** of **patient controlled analgesia**?
Analgesia **tailored** to requirements
**Safe** - risk of overdose is negligible
Accurately record how much administered - converted to **regular dose**
90
What are the **disadvantages** of **PCA**?
Cumbersome / prevent mobilisation
Not appropriate for poor manual dexterity / LDs
91
What are the **various treatments** for **neuropathic pain**?
**Non-pharmacological** = CBT, transcutaneous electric nerve stimulation
**Pharmacological** = gabapentin, amitriptyline, or pregabalin
92
What are the **patient risk factors** for **PONV**?
Female
Younger age
Previous PONV / motion sickness
Use of opioid analgesics
Non-smoker
93
What are the **surgical risk factors** for **PONV**?
Intra-abdo laparoscopic surgery
Intracranial / middle ear surgery
Squint surgery
Gynae surgery (especially ovarian)
Prolonged op times
Poor pain control post op
94
What are the **anaesthetic risk factors** for **PONV**?
Opiate analgesia / spinal anaesthesia
Inhalational agents (e.g. isoflurane / nitrous oxide)
Prolonged anaesthetic time
Intra op dehydration
95
What are the **two areas** of the brain which play a role in **control of vomiting**?
**Vomiting centre** - in the lateral reticular formation of medulla oblongata (controle and coordinates movements in vomiting)
**Chemoreceptor trigger zone** - inferoposterior aspect of 4th ventricle - outside BBB, thus responds to stimuli in circulation
96
Where does the **vomiting centre** receive input from?
CTZ
GI tract
Vestibular system
Higher cortical structures (sight, smell, pain)
97
Which **neurotransmitters** act at:
* **CTZ**
* **Vestibular apparatus**
* **GI tract**
* **Vomiting centre**
* **CTZ**: dopamine and 5HT3 receptors
* **Vestibular apparatus**: acetylcholine and histamine
* **GI tract**: dopamine receptors
* **Vomiting centre**: histamine and 5HT3 receptors
98
What are some other causes of PONV?
**Infection**
**GI causes** (post op ileus, bowel obstruction)
**Metabolic causes** (hypercalcaemia, uraemia, DKA)
**Medications** (abx, opioids)
**CNS causes** (raised ICP)
**Psychiatrica causes** (anxiety)
99
What are some **prophylactic measures** against PONV?
**Anaesthetic measures** - reduce opiates, reduce volatile gases, avoid spinal anaesthetics
Prophylactic **antiemetic** therapy
**Dexamethasone** at induction of anaesthesia (esp. follwing small and large bowel surgery)
100
What are some **conservative** measures againsts **PONV**?
Adequate **fluid hydration**
Adequate **analgesia**
Ensure no obstructive cause
101
What should patients with **impaired gastric emptying** be given?
**Prokinetic agent**: metoclopramide, domperidone (dopamine antagonists)
**Anti-muscarinic**: Hyoscine - reduces recretions and N&V
102
What should patients with **metabolic / biochemical imbalance** causing **PONV** be given?
**Metoclopramide** (for uraemia, electrolyte imbalance or cytotoxic agents)
103
What should patients with **opioid induced N&V** be given?
**Ondansetron** (5-HT3 receptor antagonist)
**Cyclizine** (H1 Histamine receptor antagonist)
104
What is **pyrexia**?
**Raised body temperature** (greater than 37.5)
105
What may be an **infective** cause of **pyrexia** on **the following days after surgery**:
Day 1-2
Day 3-5
Day 5-7
Any day
**Day 1-2**: respiratory
**Day 3-5**: UTI
**Day 5-7**: surgical site infection
**Any day**: infected IV lines or central lines
106
What are some other causes of **pyrexia** following surgery?
**Iatrogenic**: drug induced reaction (e.g. abx or anaesthetic agents) from a transfusion reaction
**VTE** (can cause low grade fever)
**Secondary to prosthetic implantation** - e.g. after AAA repair
**Pyrexia of unknown origin**
107
What is **pyrexia** **of unknown origin**?
**Recurrent fever** (\>38) persisting for **3 weeks or more** without obvious cause despite **1 week inpatient investigations**
108
What are some **causes** of PUO?
**Infection of unknown source**
**Malignancy** (B-symptoms from lymphoma)
Connective tissue disease
Vasculitis
Drug reactions
109
What to ask for in the **history** of **pyrexia** post surgery?
Ask about **systems** symptoms:
- Urinary frequency, urgency, dysuria
- Productive cough, dyspnoea, haemoptysis
- Chest / calf pain
- Wound / IV line tenderness / discharge
110
What to look for on **examination** of patient with post-op pyrexia?
Pulmonary infection
IV line infection
Wound infection
Calf tenderness
Signs of peritonism (e.g. for anastomotic leak)
111
What **investigations** to do for **post-op pyrexia**?
**Blood tests** - FBC, CRP, U&Es
**Urine dipstick**
**Cultures** - blood, urine, sputum, wound swab
**Imaging** - CXR
**CT** for **anastomotic** leak
**Doppler** US for **DVT**
112
What is the **management** of a patient with post-op **pyrexia**?
**A to E** if unwell and needs resuscitation
If **infection identified** then start empirical abx
If **no infection identified** then don't start abx - first look for non-infectious causes
113
What are some **example empirical abx** for the following infections:
## Footnote
**LRTI**
**Lower urinary tract infection**
**Upper urinary tract infection**
**Surgical site / cellulitis**
**IV line**
**Intra-abdominal**
**Septic arthritis**
**Unknown**
**LRTI** = Co-amoxiclav
**Lower urinary tract infection** = Trimethoprim
**Upper urinary tract infection** = Co-amoxiclav
**Surgical site / cellulitis** = flucloxacillin
**IV line** = flucloxacillin (vancomycin but levels need close monitoring)
**Intra-abdominal** = cefuroxime
**Septic arthritis** = flucloxacillin
**Unknown** = Cefuroxime + metronidazole + gentamycin
Unknown
114
What is **delerium**?
Acute confusional state = disturbed **consciousness** and reduced **cognitive function**
115
What are the **three main types** of **delerium**?
**Hypoactive** = lethargy and reduced motor activity
**Hyperactive** = agitation and increased motor activity
**Mixed agitation** = fluctuations throughout the day
116
How is **delerium** differentiated from **dementia**?
Delerium has **acute onset** (as opposed to insidious) it **fluctuates** (not constant) attention is **poor** (not good) delusions are **common, simple and fleeting** (as opposed to stable)
117
What are the **risk factors** for **delirium**?
**Age \> 65** years old
Multiple **co-morbidities**
Underlying **dementia**
**Renal impairment**
**Male** gender
**Sensory impairment** (hearing / visual)
118
What are the **common causes** for delerium?
**Hypoxia** (post operatively)
**Infection** (UTI / LRTI)
**Drug induced** (benzos, diuretics, opioids, steroids)
**Drug withdrawal** (alcohol / BZN)
**Dehydration** / **pain**
**Constipation** / **urinary retention**
**Electrolyte imbalance** (e.g. hyponatraemia, hypernatraemia or hypercalcaemia)
119
What to **ask** in the **history** of a patient with **delerium**?
**Onset and course** of confusion
Symptoms of **underlying cause**
**Co-morbidies** and previous **baseline cognition**
**Previous episodes**
**Drug history** (including alcohol intake)
120
What **questionnaires** can be used to assess current cognitive function?
AMT
MMSE
Confusional assessment methods - CAM - further quantifies delerium
121
What to look for on **examination** of a patient with **delerium?**
Review observations
Drug chart
Look for **signs of infection** / **pain**
Check for signs of **constipation** or **urinary retention**
122
What examination to rule out **stroke / subdural haematoma** in post op delerium?
**Neurological** examination
123
Give some example questions from the AMT?
Age
Time (to nearest hour)
Address (recall at end)
Year
Name of home addres
Current monarch
124
Which **investigations** form part of the **confusion screen**?
**Bloods** - FBC, U&Es, Ca2+, TFTs and glucose
B12 and folate can be additionally requested
**Blood cultures** and / or **wound stabs**
**Urinalysis** and / or **CXR**
**CT head** (only if relevant)
125
What is the **management** of **post-op delerium**?
Treat underlying cause **(e.g. abx for infection, oxygen if** hypoxic, laxatives for constipation)
Nursed in **quiet area, regular routines, clocks**
Encourage **oral fluid intake** and **analgesia** as necessary
126
Which **sedatives** can be used for patients with **delerium**?
**Haloperidol** (used sparingly)
Lorazepam may be needed, especially in elderly
127
What is **atelectasis**?
**Partial collape** of the **small airways** (majority of post-op patients develop)
128
Why does **atelectasis** occur?
Combination of **airway compression**, alevolar gas resporption, **decreased** production of **surfactant**
129
When does **atectasis** usually occur post operatively?
**Within 24 hours**
130
What are the **risk factors** for **atelctasis**?
**Age**
**Smoking**
Use of **general anaesthesia**
**Duration** of surgery
Preexisting **lung / neurological disease**
**Prolonged bed rest** (limited position changes)
**Poor post op pain control** (shallow breathing)
131
What are the **clinical features** of **atelectasis**?
**Increased resp rate**
**Reduced oxygen sats**
Fine cfackles over pulmonary tissue
Low grade fever
132
How is **atelectasis** diagonsed?
**Clinically**
**CXR** can show small airway collapse
133
What is the **management** of **atelectasis**?
**Deep breathing exercises**
**Chest physio** (to help with coughing)
**Adequate pain control** to help with deep breathing
If physio not adequate then **bronchoscopy** (to suction out pulmonary secretions)
134
What is **pneumonia**?
**LRTI** with **consolidation** visible on **CXR**
135
What are the **four main types of pneumonia**?
**Community acquired pneumonia** (CAP)
**Hospital acquired pneumonia** (HAP)
**Aspiration penumonia**
**Immunocompromised pneumonia**
136
Which is the most common post op pneumonia?
**Hospital acquired**
137
What is **HAP**?
**Pneumonia** with onset \>48 hours since admission and not present on admission
138
Why are **surgical patients** at a greater risk of pneumonia?
**Reduced chest ventilation** (reduced mobility = not able to fully ventilate causing secretions which become infected)
**Change in commensals** (microflora in invironment)
**Debilitation** (sick after surgery = compromised immune systems)
**Intubation**
139
**Which bacteria** commonly causes HAP?
**E. Coli**
**S. aureus** (including MRSA)
**S. pneumoniae**
**Pseudomonas**
140
Who is most at risk of **ventilator associated pneumonia**?
**Endotracheal tube in-situ**
141
What are the **risk factors** for developing **hospital acquired pneumonia**?
**Age**
**Smoking** (current / previous)
**Known respiratory disease** or recent viral illness
**Poor mobility** (baseline / post op)
**Mechanical ventilation**
**Immunosuppression**
Co-morbidities e.g. diabetes or cardiac disease
142
How do patients with **HAP** present?
**Cough** (productive / non)
**Dyspnoea**
**Chest pain**
(May not be obvious - only malaise, pyrexia or impaired cognition may present)
143
How do patients with pneumonia present?
**Bronchial breath sounds** (localised or diffuse)
**Inspiratory crackles** (on auscultation)
**Dull percussion note**
144
What are some differentials as opposed to post-op HAP?
**Acute heart failure**
**Acute coronary syndrome**
**PE**
**Asthma**
**COPD exacerbation**
**PE**
**Empyema**
145
Which **lab tests** are ordered for suspected **post-op HAP**?
**Routine bloods** (FBC, CRP, U&Es for inflammation raised WCC and CRP)
**Arterial blood gas** (showing type 1/2 resp failure)
**Sputum sample** for culture
If signs of severe infection then **blood cultures**
146
Which **imaging** for **CAP**?
**CXR** (for consolidation)
**Bronchoalveolar lavage** (if sputum sample unobtainable / non-responsive infections)
147
How can the **severity of community-acquired pneumonia** be assessed?
**CURB-65** score (0-1 = mild, 2 = moderate, 3= severe)
148
What are each given a point in CURB-65?
**Confusion**
**Urea** \>7.0mmol
**RR** \>30
**Systolic** bp \< 90 or diastolic \<60
**Age** \> 65
149
What is the management of **HAP**?
**O2 therapy** as indicated
**Empirical antibiotics** if confirmed pneumonia
150
Which **empirical abx** could be used to treat **mild-moderate** or **severe** HAP?
**Mild/moderate** = Co-amoxiclav
**Severe** = Tazocin
151
How best to **prevent post-op HAP**?
**Chest physio** post op
152
What are the **complications** of **pneumonia**?
**Pleural effusion**
**Empyema**
**Resp failure**
**Sepsis**
153
Which areas of the lungs will **aspirated** contents affect?
**Right middle OR lower lobes**
154
What are the main **risk factors** for aspiration in surgical patients?
**Reduced GCS** (secondary to anaesthesia)
**Iatrogenic intervention** (e.g. misplaced NG tube)
**Prolonged vomiting** without NG tube indertion
**Underlying neurological disease**
**Oesophageal strictures or fistulas**
Post abdo-surgery
155
How is **aspiration pneumonia** prevented?
NG tube if at risk
156
What is the management of **pneumonitis** vs **aspiration pneumonia**?
**Pneumonitis** = supportive
**Aspiration** = antibiotic therapy (similar to HAP - suction is rarely performed)
157
What does the term **VTE** refer to?
**Deep vein thrombosis** (DVT)
**Pulmonary embolism** (PE)
158
When should surgical patients be assessed for VTE?
**Admission**
After **24 hours**
159
When may a **thrombus** form?
If **Virchow**'s triad is present
160
What is **Virchow's** triad?
**Abnormal blood flow** (immobility e.g. bed-bound)
**Abnormal contents** (smoking, sepsis, malignancy, inherited blood disorders e.g. Factor V Leiden)
**Abnormal vessel wall** (atheroma or direct trauma)
161
What are the **risk factors** for a **VTE**?
Increasing **age**
Previous **VTE**
**Smoking**
**Pregnancy** (or recently post partum)
**Recent surgery** (abdo, pelvic, hip / knee)
**Prolonged immobility** (\>3 days)
HRT / COCP
Active malignancy
Obesity
Thrombophilia disorder (e.g. antiphospholipis syndrome / Factor V Leidin)
162
What is a **DVT**?
**Blood clot** in **deep veins** of a limb
163
What are the **features** of a **DVT**?
**Unilateral leg pain**
**Swelling**
Low-grade pyrexia
Pitting oedema
Tenderness
Prominent superficial veins
**65% asymptomatic**
164
What **well's score** indicates a **DVT**?
**0/1** = unlikely, D-dimer to exclude
**\> 1** = Likely, confirmed with USS (common) or contrast venography
165
Is a **d-dimer test** sensitive / specific?
**Sensitive** but **not specific**
166
What may cause a **raised D-dimer** test?
**Recent surgery**
Ongoing infection
Liver disease
Pregnancy
167
What is **first line treatment** for **DVT**? Give some examples
**DOACs** (direct oral anticoagulants) e.g. apixaban, rivaroxaban, edoxaban (direct factor Xa inhibitors)
168
Which **DOACs** require initial treatment with LMWH before commencement?
**Dabigatran**
**Edoxaban**
(Rivaroxaban and apixaban do not)
169
What is used to treat **cancer-associated** VTE?
**LMWH** alone
170
How long should **anticoagulation** be continued for after DVT?
**3 months** (provoked DVT)
**Lifelong** (persistent risk factor / high risk of recurrence)
171
What are the **causes** of a **DVT**?
**DVT**
Right sided **mural thrombus** (e.g. post MI)
**Atrial fibrillation**
**Neoplastic cells**
From **fat cells** (e.g. following tibial fracture)
172
What are the **features** of **pulmonary embolism**?
**Sudden onset dyspnoea**
**Pleuritic chest pain**
Cough
Haemoptysis (rarely)
173
What may be found **on examination** of a patient with a **PE**?
**Tachycardia**
**Tachypnoea**
**Pyrexia**
**Raised JVP** (rare)
Pleural rub
Pleural effusion
Signs of DVT
174
What **wells score** excludes a DVT (what to order to confirm)?
**Less than or equal to 4** order d-dimer to confirm
175
What if a **well's score is greater than 4**?
Confirm diagnosis with **CT pulmonary angiogram**
176
Is a D-dimer test sensitive / specific?
When else can d-dimers be raised?
**Sensitive** but **not specific**
Ongoing infection / inflammation
Concurrent liver disease
Pregnancy
177
How may a **pulmonary embolism** appear on an **ECG**?
**Right bundle branch block**, right ventricular strain
**Inverted T waves in V1-V****4** strain or rare**S1Q3T3** (deep S wave in Lead I, pathological Q wave in lead III, and inverted T wave in lead III)
178
What is the **management of**:
Haemodynamically stable PEs
PEs causing haemodynamic compromise
Recurrent PEs
**Haemodynamically stable PEs** = same as DVTs
**PEs causing haemodynamic compromise** = thrombolysis
**Recurrent PEs** (secondary to DVTs) = IVC filter
179
What options are there for **mechanical thromboprophylaxis**?
**Antiembolic stockings** (AES)
**Intermittent pneumatic compression** (IPC)
180
When should **mechanical prophylaxis** not be offered?
Peripheral aterial disease
Peripheral oedema
Local skin conditions
181
What is used for **pharmacological thromboprophylaxis**?
**LMWH** (unless poor renal function eGFR \< 30 then UFH)
182
What is **acute respiratory distress syndrome**?
**Acute lung injury** - severe **hypoxaemia** in **absence of cardiogenic cause**
183
How does **ARDS** occur?
**Inflammatory damage** to the **alveoli** causing **pulmonary oedema**, respiratory compromise and **acute respiratory failure**
184
What are the **4 points** of **acute respiratory distress syndrome**?
**Acute onset** (within 4 day)
Bilateral **infiltrates** on **CXR**
Alveolar **oedema** not explained by **fluid overload** or **cardiogenic cause**
185
What are the **direct** and **indirect** causes of **ARDS**?
**Direct** = pneumonia, smoke inhalation, aspiration, fat embolus
**Indirect** = sepsis, acute pancreatitis, polytrauma, major burns
186
What are the **three phases** of **ARDS**?
**Exudative** = initial injury causes **cytokines** and inflammatory mediators causing **direct alveolar** and **endothelial injury**
**Proliferative** = restoration of **alveolar-capillary membrane integrity** by fibroblasts and type-2 pneumocytes, new **surfactant** is also produced
**Fibrotic** = extensive **fibrin deposition** across lungs causing scarring and **long term morbidity**
187
What are the **clinical features** of **ARDS**?
Worsening **dyspnoea** (presence of related risk factor)
**Hypoxia**
**Tachypnoea**
**Inspiratory crackles**
**Acute onset** (\< 7 days)
188
What are the **differentials** to **ARDS**?
**Congestive heart failure**
**Interstitial lung disease**
**Diffuse alveolar haemorrhage**
**Drug induced lung injury**
189
What are the **investigations** for **suspected ARDS**?
**ABG** (for hypoxia)
**Routine bloods** (FBC, U&Es, amylast, CRP)
**CXR** (diffuse bilateral infiltrates)
**Echo** (exclude cardiogenic causes)
190
What imaging is **alternative** to **CXR** for **ARDS**?
**CT thorax scan**
191
What is the **management** of **ARDS**?
**Supportive** with **ventilation**
**Focused treatment** of underlying cause (early intubation and ITU admission for respiratory and circulatory support)
192
What are the **aims of ventilation** in **ARDS**?
**Maintaining minimum intravascular volume** to ensure tissue perfusion (limiting excess oedema)
**Lower tidal volumes** (reducing shear forces from over-distension)
**Positive end-expiratory pressure**
193
Is **pharma** treatment useful in **ARDS**?
Previously used **artificial surfactant** and **corticosteroids** less used now (surfactant still used in neonatal ARDS) corticosteroids may reduce ventilation days when used 7-14 days after onset
194
What are the **key prognostic factors** for **ARDS**?
**Increasing age**
**Co-morbidities**
**Active malignancy**
**Liver disease**
195
What is an **anastomotic leak**?
**Leak of luminal contents** from a **surgical joint**
196
What are the **patient** and **surgical factors** which increase the risk of an **anastomotic leak**?
**Patient** = corticosteroids, smoking, alcohol excess, diabetes, obesity
**Surgery** = emergency surgery, longer intra-op time, oesophageal-gastric or rectal anastomosis
197
What are the **clinical features** of an **anastomotic leak**?
**Abdo pain**
**Fever** (5-7 days post op)
Delerium
Prolonged ileus
198
Examination findings for **anastomotic leak**?
**Pyrexia**
**Tachycardia**
Signs of **peritonism**
199
What are the **investigations** of an **anastomotic leak**?
**CT scan with contrast** of abdo-pelvis (definitive investigation)
FBC
CRP
U&Es
LFTs
Clotting screen
Venous blood gas (to assess tissue perfusion)
G&S for possible surgery
200
What is the **inital** and **definitive management** of an **anastomotic leak**?
**Initial** = nil by mouth, broad spectrum abx, IV fluid therapy, insert urinary catheter (monitoring fluid balance)
**Definitive**
Minor leak (collection \< 5cm) = IV abx
Large = drained percutaneously / surgical intervention
Septic = exploratory laparotomy (wash outs, drain insertion)
201
What type of **bowel obstruction** is **post-op ileus**?
Functional
202
What are the **patient** and **surgical risk factors** for **post-op ileus**?
**Patient** = increased age, electrolyte derangement (Na, K Ca), neurological disorder, anti-cholinergic medication
**Surgical** = opioid medication, pelvic surgery, extensive intra-operative intestinal handling, peritoneal contamination, intestinal resection
203
What are the **features** of **post-op ileus**?
Failure to **pass flatus / faeces**
**Bloating** and **distension**
N&V
**Absent bowel sounds** (if mechanical then 'tinkling' heard)
204
What are the **investigations** for **post-op ileus**?
**Initial routine bloods** (FBC, CRP, U&Es - fluid shifts in adynamic bowel causing AKI)
**Electrolytes** (calcium, potassium, magnesium)
**CT abdo pelvis** (with contrast) to confirm diagnosis
205
What is the **management** of **post-op ileus**?
Once **anastomotic leak excluded** then conservative management:
* NBM
* IV fluids
* Daily bloods (correct abnormalities and monitor for AKI)
* Encourage mobilisation
* Reduce opiate analgesia
**Once it does settle** = watery stool for first 2-3 bowel movements
206
What are the **preventative steps** for **post-op ileus**?
**Minimise** intra-op **intestinal handling**
**Avoid fluid overload**
**Minimise opiate** use
Encourage **early mobilisation**
207
What are **adhesions**, and **when can they occur**?
**Fibrous bands** of scar tissue
Secondary to **previous surgery** or **intra-abdominal inflammation** (pelvic) also **congenital**
208
How do **adhesions** present?
Infertility
Chronic pelvic pain
209
How should **bowel adhesions** be investigated and managed?
**Bowel obstruction** = tube decompression, NBM, IV fluids, analgesia
**Surgical management** (for features of ischaemia, perforation or failed conservative management) = adhesiolysis (only for adhesions causing mechanical obstruction / strangulation) laparoscopically or opwn
210
How can **adhesions be prevented**?
Correct surgical technique
Reducing intraperitoneal organ handling
211
What are the **risk factors** for **incisional hernias**?
**Emergency surgery**
**BMI** \> 25
**Midline incision**
**Wound infection**
**Pre-op chemo**
**Pregnancy**
**Advancing age**
212
What complications can occur with hernias?
**Incarceration** (irreducible)
**Strangulation** (blood supply compromised)
**Bowel obstruction**
213
What are the **features** of an **incisional hernia**?
**Non-pulsatile**
**Reducible**
**Soft**
**Non-tender swelling**
214
How may an **incarcerated hernia** present? And with obstruction
Painful
Tender
Erythematous
**Obstruction** = distension, vomiting, constipation
215
What else may cause an **abdo lump**?
**Lipoma**
216
What **investigation** for **incisonal hernia**?
**Clinical diagnosis**
US / CT = diagnosis unclear
217
What is the **management** of an **incisional hernia**?
Surgery for **painful hernias** (suture repair, laparoscopic mesh repair, open mesh repair)
218
What are the **complications** of **incisional hernia repair**?
Pain
Bowel injury
Seroma formation
219
What is the **prognosis** of **incisional hernias**?
If no surgery then asymptomatic / incarcerate / strangulate
If surgery then possible chronic pain
220
What is **post-op constipation** defined as?
**Infrequent bowel movements** (\<3 per week) with **hard, dry stools**
221
What are the main causes of **constipation** on **surgical wards**?
**Physiological** - low fibre diet, poor fluid intake, low physical activity
**Iatrogenic** - opioid analgesia, anticonvulsants, iron supplements or antihistamines
**Pathological** - bowel obstruction, hypercalcaemia, hypothyroidism, neuromuscular disease
**Functional** - painful defecation (e.g. anal fissures)
222
What are the **features** of **constipation**?
**Lower abdo pain**
**Abdo distension**
**N&V**
**Decreased appetite**
223
What examination for constipation?
DRE
224
What bloods may be requested for constipation?
TFTs
Serum calcium
225
Is imaging required for constipation?
**Generally no**, unless obstruction suspected (Abdo XR, CT scan, endoscopy)
226
What is the **management** of **post-op constipation**?
**Conservative** = hydration, sufficient dietary fibre, early mobilisation
**Pharma** = osmotic laxative (increase fluid in bowel e.g. lactulose, movicol), stimulant laxative (e.g. senna, picosulphate), bulk forming (help stool retain watere.g. ispaghula husk), rectal medication (e.g. glycerin suppository OR phosphate enema both stimulants)
227
What to give:
Patient with hard stool / chronic constipation =
Post-op ileus =
Resistant constipation =
Patient with hard stool / chronic constipation = movicol / lactulose (glycerine suppository to help initally)
Post-op ileus / opioid induced = senna / picosulphate
Resistant constipation = manual evacuation or enema
228
229
How can **AKI be defined**?
\>**50% rise in serum creatinine** from baseline in last 7 days
**Urine output** \<0.5mls/kg/hr for \> 6 hours
230
How can **severity of AKI be decided**?
Stage 1 = 1.5-1.9 times the baseline
Stage 2 = 2-2.9
Stage 3 = \> 3 times baseline
231
What are some **pre-renal causes** of **AKI**?
**Sepsis**
**Dehydration** (including pre-op NBM or bowel prep)
**Haemorrhage**
Intra-op (accidental graft occlusion, proximal aortic clamp for too long)
232
What are some **intra-renal** causes of **AKI**?
**Nepohrotoxins** e.g. NSAIDs, ACEi, aminoglycosides, chemo
GN, rhabdomyolysis, HUS, multiple myeloma
233
What are some **post-renal** causes of **AKI**?
**Ureteric** = bilateral renal stones, tumours
**Bladder** = acute urinary retention, blocked catheter
**Urethral** = prostatic enlargement (BPH or malignancy), renal stones
234
What are the **investigstions** for **AKI**?
**Examine** patient
**Bladder scan** (retention)
**Review drug chart** (nephrotoxins)
**Urine dip** (specific gravity and osmolality will be higher in pre-renal causes but Na excretion will be lower, GN show blood and protein)
**Bloods** (U&Es, FBC, CRP, LFTs and Ca2+)
**US scan** - KUB (obstruction)
235
What is the **management** of **AKI**?
**Resus** if critically unwell (especially if pre-renal)
Assess **hydration status** (look for signs of dehydration - dry mucous membranes, increased cap refil, reduced skin turgor, tachycardia)
**Start fluid balance chart** (consider catheterisation to accurately assess)
**Regular blood tests** to monitor serum creatinine
236
Which drugs should be **stopped** or **altered** in **AKI**?
**Stopped** = NSAIDs, ACEi, ARB, aminoglycoside abx, potassium-sparing diuretics (due to increased risk of hyperkalaemia)
**Altered / reduced** = metformin (lactic acidosis), diuretics (intravascular-fluid depletion), LMWH
237
What are the **features** of post-op **urinary retention**?
**Little** / no **passed urine**
Senation of needing to void without being able to micturate
**Suprapubic mass** - dull to percuss
238
What are some **common causes** for **post-op** urinary retention?
**Uncontrolled pain**
**Constipation**
**Infection**
Anaesthetic agents
239
What are some **risk factors** for **post op-urinary retention**?
**Age** \> 50 y/o
**Male gender**
**Previous retention**
Pelvic / urological surgery
**Neuro** co-morbidities
**Medications** (e.g. anti-muscarinics, alpha agonists, opiates
240
How to **assess** post op **urinary retention**?
**Ultrasonic bladder scan** (assesses post-void residual volume - should be negligible)
**U&Es**
Check for reversible causes (pain managed?)
241
What is the **management** of **post-op** urinary retention?
**Catheterisation**
**TWOC** (if fail then reinserted and retried in 1-2 weeks)
242
Which **organisms** commonly cause **UTI**?
**E. Coli**
**Klebsiella sp.**
**Enterobacteur sp.**
**Proteus sp.**
**Pseudomonas sp.**
**Staphylococcus sp.**
243
What are the **risk factors** for **post-op UTI**?
Age \> 60
Female
Co-morbidities e.g. renal failure, diabetes
Catheterisation
Pregnancy
Urinary retention
244
What are the **clinical features** of **UTI**?
**Urinary frequency**
Urgency
**Dysuria**
Suprapubic pain
Pyrexial
(delerium, septic, pyelonephritis - loin pain)
245
What are the **investigations** for **post-op UTI**?
**Urine dip** (might show sterile pyuria - isolated raised WCC due to STI, renal stones, half treated UTI)
Send mid-stream sample for MC&S (if nitrites / blood)
**Bloods** (FBC, CRP, U&Es, blood cultures, VBG) depending on clinical picture
**Bladder scan** if retention
If **pyelonephritis** suspected then US
246
What is the **management** of **post-op** **UTI**?
Ensure **well hydrated** (PO / IV)
**Abx** (start empirical and change if poor response, replace catheter before starting if applicable)
247
What are the **risk factors** for **hypoglycaemia**?
**Diabetes mellitus**
**Post-gastrectomy**
**Alcohol excess**
**BBs** (inhibit liver gluconeogenesis)
248
What are the **features** of **hypoglycaemia**?
**Sweating**
**Tingling lips**
**Tremor**
**Dizziness**
**Slurred speech**
249
What are the **clinical signs** of **hypoglycaemia**?
Pallor
Confusion
Tachycardia
Tachypnoea
Focal neurology
250
What is **gastric dumping syndrome**?
How can it be managed?
Following **gastric bypass surgery**
10-30 mins post-prandial = sudden hypertonic gastric content in small intestine results in intraluminal fluid shift and intestinal distension (N&V, diarrhoea, hypovolaemia causing tachycardia and diaphoresis)
1-3 hours after = **surge in insulin** causes **hypo**
Managed with **small volume and more frequent meals** (avoiding simple carbs
251
What are the **investigations** of **hypoglycaemia**?
**BM** measurement (serum blood glucose)
(have they been starved pre-op? do they have liver disease?)
252
What is the **management** of **hypoglycaemic patients**?
A-E
**If conscious** = oral glucose (lucozade) and complex carbs (bread) and **monitor BM** every **1-2 hrs** (if no improvement start IV 10% dextrose)
**If unconscious** = protect airway and give high flow O2, give **IV glucose** or IM glucagon
253
What is the **glucose monitoring** intra-operatively for **diabetic patients**?
BM taken regularly every **30 mins** (if \<4 mmol at any point then IV glucose increased and insulin infusion stopped, recheck after 30 mins, if \<2mmol then treat as hypoglycaemic emergency)
If major surgery then consider **variable rate insulin infusion device** (should be continued until pt is eating and drinking normally, if T1DM then continue for 30 min after normal SC insulin injections are given)
254
What is **hyperkalaemia**?
**Serum potassium \> 5.5 mmol/L**
255
What are the **causes** of **hyperkalaemia**?
**Post-op AKI**
**Repeated blood transfusions**
**Drugs** (spironolactone, ACEi)
**Excessive potassium treatment**
256
What are the **investigations** for **hyperkalaemia**?
**Bloods** (including U&Es, Ca2+ and PO42- and Mg2+)
**VBG** (for immediate result of patients potassium levels)
**ECG**
**Catheterisation** for fluid balance monitoring
257
What are the **ECG** findings in **hyperkalaemia**?
Tall tented T waves
Small indiscernible P waves
Prolonged QRS (eventually merges with T wave)
